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WELL LOCAT ON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �o��,Name WELL AND BORING RECORD 6 5 5 0 5 7 x�nfl� �n Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed tt Oroao 117 23 OS �. �. ��. 135 1-3-01 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 3't 2'�T F Lake J� 0 r�h0 5 S 3 5 6 � Cable Tool ❑ Driven ❑ Dug � Auger g-'Rotary ❑ Jetted Show exact location of well in section ri ith"X". Sketc a of well location. ❑ � 9 L��`E ow Pg property lines, roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �,�'NO N �� '� ��`L SLt er —X FROM n.to K. _� � � �_ � — � -�- -�- -� USE ❑ Monitoring �j Heating/Cooling i i � i �Domestic _i_ _a_ _i_ _i_ � ❑ Community PWS �7 Industry/Commercial i i i i � ❑ Irrigation ❑ Noncommunit PWS w e T \, ❑ Environ.Bore Hole Y ❑ Remedial i i � i .�� ❑ Dewatering ❑ i y r i '2IM.ia q CASING Drive Shoe? ❑ Yes �No HOLE DIAM. _i i i i_ � � ❑ Steel ❑ Threaded ❑ Welded i_ _i_ _i _ _i �Plastic ❑ �1 Mile-� � CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME _.f,�_in.to�_"��ft. ��_'�' ,�__Ibs./ft. ��/t�__n, Q TO� �a in.to h. IbsJfl. ��- in.to � � v Property owner's mailing address if different than well location address indicated above. _in.to ft. __ Ibs./ft. in.to__ft. SSNe IIB above SCREEN OPEN HOLE Make ____ from tt.to tt. Type�_ _Diam. 9« SIoUGauze Leng[h • Set between ft.and . FITTINGS: - er S STATIC WATER LEVEL 'w � WELL OWNER'S NAME /� tt. [R'below ❑ above land surface Date measured�_�_��_� —I.��-------- PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. __1.�Q______ft. after_ 1�5 hrs.pumping__�__g.p.m. WELL HEAD COMPLETION �Pitless adapter manufacturer__�.�$��_ Model ___ __ f7 Casing Protection_._,_ _ ____ ___ �12 in.above grade ❑ Ahgrade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted7 '6X Yes ❑ No HARDNESS OF �f GEOLOGICAL MATERIALS COLOR FROM TO Grout Material ❑ Neat cement ❑ Bentonite !1 Concrete J3 High Solids Bentonite MATERIAL from.__�__ to __�Q_ft. ____�_�� yds.� bags j Ly r from__�_to_}�_�tt. n�i.�..�1 ❑tVds.tCl bags t��$DiZ U18CIl +,��Lt 0 from_ . ._ to _.—___h. C�Gj i ❑lydslO bags NEAREST KNOWN SOURCE OF CONTAMINATION r peat b��9C� S�1 t 2 2 —��l feet _ �/�L�S��_direction �l/ � type Well disinfected upon complelion? �L Yes -1 No � !� L r1 �` C. L /G clay gray soft Z$ H PUMP , � ❑ Not installed Date installed 1�1�7�01 sandJgravel colored $�ft O'i 9 Manufacturer'sname _ _ �8�_ ______ '^�:. .0 Model number _.__. __.___ HP ��a___ Volts 7�n � C l�y �jr8y ��t t �� I 15 Length of drop pipe �� _ _____ _ R. Capacity __��___._ g.p.m. sand/gravel, cliored $��t 115 12 Type �Submersible ❑ LS Turbine fl Reciprocating C] Jet ❑ ABANDONED WELLS :``� ` Does property have any not in use and not sealed well(s)? ❑ Yes �No s8�d tan 30�t �Zv �� VARIANCE Was a variance granted from the MDH for ihis well? ❑ Yes �o TN# WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The information contained in this report is true to the best of my knowledge. icensee usiness� ame c.o g.No. rTlG�G� 7 2 s --L-_?.�_�L !�r��zed Representa(ive Signature � Date —__ Duane itathews_____1-3-Q1 � � � ^ O� � � NameolDriller Date LOCAL COPY �'* `•J HE-01205-07(Rev.2/99)